Provider Demographics
NPI:1548574767
Name:WASSERSTEIN, JACK ELLIOT (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ELLIOT
Last Name:WASSERSTEIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27450 TOURNEY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1828
Mailing Address - Country:US
Mailing Address - Phone:661-254-8484
Mailing Address - Fax:661-254-8669
Practice Address - Street 1:27450 TOURNEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1828
Practice Address - Country:US
Practice Address - Phone:661-254-8484
Practice Address - Fax:661-254-8669
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA362971223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics